A 41yo man with a background of type 1 diabetes was admitted with starvation ketosis and sepsis secondary to multiple necrotic soft tissue wounds obtained on a remote solo bush walk.
On presentation, the patient was alert and orientated. Initial tests showed hyperglycaemia with ketosis but normal acid base balance. Inflammatory markers were markedly elevated. Multiple scratches and cuts were noted as well as broad necrotic wounds on both feet, knees and right thigh as well as an infected right elbow bursa. Intravenous fluids, antibiotics and insulin infusion were commenced. The Plastic Surgical team arranged surgical washout and debridement that afternoon.
Induction of anaesthesia was complicated by low oxygen saturation and tachycardia. On insertion of the endotracheal tube, systolic blood pressure rose to 280mmHg. Esmolol 60mg was administered with no change in blood pressure. Medication error and arousal were excluded. A GTN infusion was commenced for the short procedure.
Post operatively; the patient was diaphoretic, febrile, tachycardic and hypertensive. Intravenous metoprolol was required over the next 2 hours after which the patient was transferred to the intensive care unit. Differential diagnoses considered included septic shower or aspiration pneumonia.
Urgent plain film of the chest was normal. Contrast CT demonstrated an 8.2 x 6.8cm right adrenal mass prompting 24-hour urine catecholamines and plasma metanephrines, which were markedly elevated. Metaiodobenzylguanidine scan showed varying uptake at the periphery of the adrenal mass suggestive of phaeochromocytoma, with no extra adrenal uptake. FDG PET detected no FDG avid disease, indicating low probability of high-grade adrenal malignancy.
Treatment was initiated with Phenoxybenzamine up- titrated to 30mg daily. A high salt diet was commenced and Metoprolol 25mg bd was added prior to laparoscopic adrenalectomy.
Histopathology confirmed a phaeochromocytoma with no malignant features. Mutational analysis of the tumour showed normal staining for SDHB and SDHA.